From the Guidelines
Not all infected ingrown toenails require resection in the Emergency Department, and a conservative approach with antibiotics and local care should be considered first, reserving surgical intervention for severe cases or when conservative management fails. The management of infected ingrown toenails should prioritize reducing morbidity, mortality, and improving quality of life. According to the most recent and highest quality study available, which focuses on the management of foot infections and related conditions 1, the approach to paronychia, which can include ingrown toenails, involves grading the severity of the condition and tailoring the treatment accordingly. For mild to moderate infections, conservative treatment including warm soaks, topical or oral antibiotics, proper nail trimming, and elevation of the affected foot can be effective. Oral antibiotics such as cephalexin 500mg four times daily, clindamycin 300mg four times daily, or amoxicillin-clavulanate 875/125mg twice daily for 7-10 days may be considered. Patients should also be advised to wear open-toed shoes or sandals to reduce pressure on the toe.
Key considerations for determining the need for surgical intervention include:
- Severity of the infection
- Presence of purulent drainage
- Significant erythema extending beyond the nail fold
- Severe pain
- Systemic symptoms like fever
- Failure of conservative management
The guidelines from 1 suggest that for Grade 3 or intolerable Grade 2 paronychia, which could correspond to severe infected ingrown toenails, surgical intervention or antibiotics may be indicated, and partial nail avulsion could be considered. However, the decision to proceed with surgical intervention should be made on a case-by-case basis, taking into account the severity of the infection, the patient's overall health, and the potential risks and benefits of the procedure. Earlier guidelines, such as those from 1 and 1, while focusing on diabetic foot infections, emphasize the importance of urgent surgical intervention for severe infections but do not directly address the management of infected ingrown toenails. Therefore, the approach should prioritize conservative management initially, reserving surgical intervention for cases that meet specific criteria indicating a need for more aggressive treatment.
From the Research
Infected Ingrown Toenails Treatment
- Not all infected ingrown toenails require resection in the Emergency Department (ED) 2.
- Treatment approaches for ingrown toenails vary, including podiatric treatment, surgical treatment, and conservative treatments 3, 4, 5, 6.
- Surgical treatment options include chemical matrixectomy, mechanical resection of the lateral matrix horn, and other techniques such as the Winograd technique and Vandenbos procedure 4, 5, 6.
- The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity 2.
- Partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix are equally effective in the treatment of ingrown toenails 5.
- The choice of procedure depends on the severity and recurrence of the ingrown toenail 4.
Treatment Outcomes
- Mean healing times for patients with infected ingrown toenails treated with a chemical matrixectomy alone or with oral antibiotics were similar 2.
- The use of traumatic surgical techniques such as the "Emmert plasty" or wedge excisions is not recommended 3.
- Complications of surgical procedures include regrowth of a nail spicule secondary to incomplete matricectomy and postoperative nail bed infection 6.